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Opioid prescriptions after heart surgery might have turned some patients into chronic users, a study suggested, such that curbs on initial amounts prescribed may be warranted.

Among 35,817 patients who filled an opioid prescription within 14 days following coronary artery bypass grafting (CABG) or heart valve surgery, 9.6% of them became persistent opioid users by 90-180 days, according to Nimesh Desai, MD, PhD, of the Hospital of the University of Pennsylvania in Philadelphia, and colleagues.

The higher the number of these pain pills prescribed, the greater the risk of dependency. A threshold of 300 mg oral morphine equivalents -- approximately 40 tablets of 5-mg oxycodone -- distinguished patients who were likely to develop persistent use, the authors reported online in .

"Cardiothoracic surgeons, cardiologists, primary care clinicians, and advanced practitioners should all enact evidence-based protocols to identify high-risk patients for persistent use and minimize opioid prescriptions postoperatively with multimodal analgesia techniques," Desai's group urged.

"The scale and scope of the epidemic require a multifaceted response, including partnership between policy makers, specialty societies, and clinicians at the bedside," agreed Steven Farmer, MD, PhD, of the Centers for Medicare and Medicaid Services in Baltimore, and colleagues in an invited commentary.

A good example of such collaboration, they wrote, is the Bundled Payments for Care Improvement Advanced payment model, which has the Substance Use Screening and Intervention Composite as a quality measure applied to all surgical episodes.

Furthermore, high-risk patients in particular may benefit from Enhanced Recovery After Surgery protocols, which are designed to reduce the stress of surgery, enhance functional recovery, reduce opioid use, and integrate multimodal pain management plans, Farmer's team added.

The retrospective cohort study was based on administrative claims from an Optum database of adults with private insurance or Medicare-managed coverage. All were deemed opioid-naive in the 180 days before the index surgery in 2004-2016.

Most underwent CABG (71.7%), the rest had heart valve procedures. Valve procedures were associated with reduced risk of persistent opioid use (8.1% vs 10.2% after CABG, OR 0.78, 95% CI 0.70-0.86).

Other factors that put patients at higher risk of opioid dependence were:

• Female sex (OR 1.15, 95% CI 1.03-1.26)
• Younger age (OR 1.02, 95% CI 1.01-1.02)
• Congestive heart failure (OR 1.17, 95% CI 1.06-1.30)
• Chronic lung disease (OR 1.32, 95% CI 1.19-1.45)
• Diabetes (OR 1.27, 95% CI 1.15-1.40)
• Kidney failure (OR 1.17, 95% CI 1.00-1.37)
• Chronic pain (OR 2.71, 95% CI 2.10-3.56)
• Alcoholism (OR 1.56, 95% CI 1.23-2.00)
• Benzodiazepine use (OR 1.71, 95% CI 1.52-1.91)
• Muscle relaxant use (OR 1.74, 95% CI 1.51-2.02)

"Identifying these high-risk patients before surgery who may be at increased risk for persistent opioid use is critical. However, when we performed the analysis after excluding these high-risk patients, we found the incidence of persistent opioid use was 8.2%," the investigators noted.

"This illustrates the multifactorial causes of the opioid crisis and that persistent opioid use after surgery may be associated with other unmeasurable factors, such as opioid marketing and cultural factors," they added.

Their reliance on the administrative database meant the data were subject to potential coding errors and misclassification. Generalizability of the findings was questionable given the exclusion of patients younger than 18 years and those without private insurance.

"While we attempted to exclude patients who had additional anesthesia and surgery, it is not possible to know with certainty if an opioid prescription that was prescribed within 90 to 180 days after surgery is because of the prolonged opioid use or an acute pain issue," Desai's team added.

Other limitations included the lack of data showing that patients actually used all the opioids prescribed. Moreover, the investigators couldn't be sure that patients didn't acquire opioids from alternative sources.

Nevertheless, there is "certainly room for improvement in opioid prescribing," the editorialists said. "The U.S. has a 3-fold geographic variation in opioid prescriptions of 30 days or longer, and the rate of long-term opioid use after major surgery in Canada is far lower at 3.1%."

A showed that in 2017, 17.4% of the U.S. population received at least one opioid prescription -- the average person among these receiving 3.4.

"More judicious use of postoperative opioids could narrow the current-day opioid epidemic by minimizing opioid exposure in the first place," Farmer and colleagues urged.

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